Warning: if you are an NHS manager, or married to one, skip this blog post. This is not for you. There’s nothing to see here. Move along, please.

The NHS is a leviathan organisation. It employs well over a million people, making it the world’s fifth largest employer, and spends roughly £200 billion a year on health and social care, about 10% of UK GDP. The NHS obviously needs to be managed, and about a quarter of its employees are either managers or administrative staff. There are NHS managers at national level including the Secretary of State for Health and Social Care, ministers of state for health, under-secretaries of state for health, and DOH civil servants. Myriad organisations manage the NHS top-down, such as NHS England and the allied organisations in the devolved nations, NHS Employers, NHS Providers, the NHS Business Services Authority, NHS Resolution, NHS Digital, and the NHS Confederation. Then there are senior hospital executive managers, middle hospital managers and, further down the pecking order, departmental managers.

When discussing the problems of the NHS, its managers tend to get a bad press. When you have worked in the organisation at senior level for as long as I did, you do gain a certain perspective. I have drawn my own conclusions about the management of the NHS and its managers. What follows is a personal view. You are free to agree or disagree with it as you will. I’m not going to talk about how the NHS is managed at a national level in this post, however. That treat will have to wait. The politicians get a post all to themselves. After all, I’ll need all the space I can get to cram in everything I don’t like about how our elected politicians run our health services. 

The Executive Team (execs)

The fight against death and disease is said to take place on the NHS frontline. If the health secretary is the Field Marshall directing strategic operations from a French château miles behind the action in the trenches, then the Executive Team are the senior officer corps, urging their troops to go over the top from the safety of their fortified bunkers. The general commanding the execs is the hospital’s Chief Executive Officer (CEO). The brigadiers and colonels comprising the rest of the Executive Team include any or all of the following: a director of operations; a director of workforce and operational development; a director of communications; a director of strategic planning; a director of finance; a medical director (a senior doctor); a director of nursing (a senior nurse). Immediately below the exalted ranks of the execs are dozens of middle managers, the captains and majors. Under these are countless lieutenants doing their thing in every nook and cranny of the hospital from the ICU to the coffee shop, from the operating theatre to the outpatient clinic, from the Emergency Department to the car park.

The job of the Executive Team is to keep the hospital running, achieving its treatment targets while keeping within its financial budget. In my experience, they weren’t always up to the job and called in external management consultants to advise them whenever the going got tough. These companies always went by flamboyant acronyms such as WNKR Associates, FCKU  Creative or BLLCKS Consulting Group. They came up with madcap schemes to save money, such as making senior medical and nursing staff compulsorily redundant, selling off parts of the hospital site for housing development even though that land might be needed in the future, and quadrupling staff car parking charges.

I once suggested to one of our execs that it was actually the Executive Team’s job to do precisely what they’d just brought the external consultants in to do. Weren’t they just a tad embarrassed at not being capable of tackling it themselves? The answer I received was that they were all far too busy firefighting the many acute problems threatening the day-to-day viability of essential services to worry about strategic planning or organisational change. So I suggested they could have consulted the senior medical and nursing staff instead. We would have been much cheaper and would likely have come up with more sensible ideas to develop services and reduce waste and inefficiency in a sustainable way than the so-called experts. Sadly, the NHS is an archetypal top-down organisation, and the notion that the people working on the shop floor might know better than the suits how to improve things doesn’t sit naturally with NHS managers.

Chief Executive Officer (CEO)

CEOs of hospitals are rather like Premiership football managers. They move from hospital to hospital every five years or so, trying to take each one to the top of the league table for four-hour waits in the ED, meeting cancer pathway targets, achieving the best patient satisfaction survey scores, doing more with less, etc. When they first start at a new club hospital, there is a surge in hope, optimism and enthusiasm for a brighter future, at least among the other execs and members of the hospital’s Trust Board, which has just appointed said new CEO  (we’ll hear about this talking shop later). The new broom will sweep out the crud and detritus of ingrained inefficiency, lackadaisicalness and poor practice, the Board members think, to be replaced by improved, more streamlined and efficient structures and processes. The end result? Better outcomes for patients? Soaring staff morale? Perhaps. Perhaps not. That’s hardly the point, though. Cost savings are the way forward. And performance bonuses for the managers.

Sadly, reality seldom matches the vision. But then, it really isn’t possible to improve efficiency or increase productivity when everyone is already working their bollocks off, including countless hours of unpaid overtime. When everyone is doing the work of two people, cross-covering the huge gaps in the workforce. The vacancies have remained unfilled for years because nobody wants that much stress and responsibility for so little pay, or because there aren’t the funds to employ replacements. It’s difficult not to be cynical about the airy pontifications of a new CEO and their grand five-year plan when you’re constantly running around like a blue-arsed fly, doing your best to do an adequate job. There was a wall poster in the theatre coffee room with the caption: The floggings will continue until staff morale improves. It wasn’t far from the truth.

As the brand new, shiny CEO tarnishes and the wheels come off the hospital wagon one by one, the writing is on the wall when it becomes clear that none of the clinical targets is being met. The Chair of the hospital’s Trust Board now feels compelled to declare total confidence in the CEO. Speculation is immediately rife about how long the CEO will last. Sweepstakes are organised, gambling on who might take over. The last straw is the publication of the end-of-year financial accounts. The budget has been blown to smithereens. The annual financial deficit has sky-rocketed. Widespread rumours circulate that the hospital will go bankrupt and be taken over by the neighbouring teaching hospital.

Inevitably, the CEO moves on. I say move on, rather than be sacked, advisedly. Returning to the football manager analogy, the CEO departs on the best of terms with the Chair of the Board (they are probably both members of the local golf and Rotary clubs), who publicly thanks the ex-CEO profusely for doing such a sterling job under such challenging circumstances. There is a generous severance payment, naturally, and just like a football manager whose club hasn’t won a trophy yet again this year, the CEO transfers seamlessly to another hospital on an even higher salary. Hey-ho. Nice work if you can get it.

Director of Operations

I haven’t much to say about this role because I was never clear on what a Director of Operations actually did that the CEO wasn’t already supposed to be doing. Perhaps they took turns running things while the other took it easy.

Director of Workforce and Operational Development

They are basically what used to be called personnel or human resources directors, and implement policy regarding the hiring and firing of staff, their terms and conditions of employment, policies on sickness absence, disciplinary matters, remediation, and so on. They do a proper job, one I could understand.

Director of Strategic Planning

It seems to me that this job was a sinecure given that I saw precious little strategy or planning during my hospital career. None that made any sort of sense or involved anything more than the hospital limping to the end of the current financial year without going bust, anyway.

Director of Communications

Their main job is to spread propaganda publish press releases for the local news media, telling the local populace how thoroughly marvellous the hospital is. The recently published, appallingly bad Care Quality Commission (CQC) report should absolutely not be taken at face value. All manner of measures have since been put in place, rendering the 126 pages detailing the special measures to be implemented redundant. What’s more, you can jolly well tell all your readers that the hospital is definitely not in danger of going bust because it can’t afford to pay the electricity bill due next week, even though it may be true that a small number of ventilator-dependent patients on the ICU are reliant on their friends and family putting coins in the recently installed electricity meters.

The Director of Communications also oversees the printing of glossy pamphlets, magazines, and booklets extolling the virtues of the hospital for staff, patients and visitors to read when they’ve nothing better to do. It’s an utter waste of money because nobody ever does read them, no matter how bored they are. The glossies do find use as doorstops, something to lean on while you are writing and as the raw material for making paper planes, though.

Director of Finance

This is the big one! I’ve a lot to say about this, which might come as some surprise, because I know sod all about money, budgets, an organisation’s finances, or how to balance the books while still providing first class clinical services. Funnily enough, those are the self-same traits of your average NHS Director of Finance.

Everybody has a fair idea what being the Director of Finance is all about. I always felt sorry for whichever poor sod was the present incumbent. It can’t be easy for anyone to take on the thankless task of trying to keep an NHS hospital solvent. A poisoned chalice if ever there was one. Why not take on something less stressful and more achievable? Like coaching the England men’s football team to win the next World Cup, for example. Or becoming Kier Starmer’s special advisor, making him so popular in the country that he storms into Downing Street with a landslide victory at the next general election.

Every year we underlings would be informed that we had to make a zillion pounds’ worth of efficiency savings. Every year, the service would be cut not to the bone but through it. When I say service, I mean clinical rather than management activity. And every year it would transpire that the cuts, as brutally savage as they had been, had only saved half a zillion pounds (it would have been more, but a new tranche of managers had to be recruited to oversee the implementation of the cost-saving measures). What it all boiled down to was that next year, two zillion pounds’ worth of efficiency savings needed to be found.

The execs took this caper very seriously, whereas most of us on the frontline thought it was just Alice in Wonderland economics. However, valuable clinical staff with years of knowledge and experience under their belts lost their jobs on the back of this philosophy, being made redundant or resigning under the intense pressure of not having the time or tools to properly care for patients. Equally as important, the NHS lost valuable, irreplaceable clinical staff. Those who remained suffered from low morale and the seeds of their ultimate burnout were sown. The NHS then lost their services, too, when they took early retirement.

This perfect storm could have been so easily avoided if NHS funding and hospital finances had not been so divorced from economic reality and so subject to the political caprices of the government of the day. It took the advent of the COVID pandemic to provide a way out of the financial mayhem in hospitals across the UK, which were severely indebted and at risk of bankruptcy. At a wave of the Health Secretary’s, Matt Hancock’s, magic wand, he disappeared £13.4 billion of historic NHS hospital debt. Every last penny of it was written off at a stroke. Just like that! Tommy Copper couldn’t have done it better. What a pity none of Matt’s predecessors hadn’t waved the government’s magic wand years earlier. Then, perhaps, the NHS wouldn’t have lost so many good people and would therefore have been better prepared and able to deal with the challenges of managing COVID.

Medical Director

The MD is usually a senior consultant in a hospital. It’s their job to ensure that all the doctors working within the hospital are safe, competent and working to established, evidence-based protocols and procedures. Another thankless task if ever there was one. Not for me.

Director of Nursing

A senior nurse or midwife working in a hospital with analogous roles and responsibilities to the MD.

Hospital Board (NHS Trust Board)

The members of the hospital’s Executive Team handle day-to-day operational management, making and implementing hospital policy at a tactical level. However, the execs, including the CEO, are directly accountable to the Hospital Board (usually known as an NHS Trust Board because NHS hospitals are legally defined as self-governing, public sector organisations within the NHS).

Similar to a school board of governors or a corporate board of directors, an NHS Trust Board is the body with overarching strategic responsibility for a hospital, including its performance, long-term planning, governance, CQC compliance, and financial oversight. Crucially, the board is entirely responsible for choosing and appointing the CEO and other members of the Executive Team. It is accountable to NHS England (or analogous organisations in the devolved nations of the UK), the Secretary of State for Health, Parliament, and the local community.

The composition of an NHS Trust board is divided roughly 50:50 between the CEO and other key executive directors on one side, and independent non-executive directors on the other. These independent directors are usually leading figures from the local community, often entrepreneurs and business leaders, or retirees who previously held senior roles in healthcare, education, IT and related fields.

I never worked out what the Trust Board members actually did to earn their corn. It seemed to me that the non-execs merely rubberstamped whatever policies the CEO and Executive Team were pushing. Most people I worked with wouldn’t have been able to name a single member of the Trust Board if their life had depended on it, so divorced were they from life on the NHS frontline. The Chair would appear in a short motivational video on the Intranet from time to time to give a stirring pep talk, motivating the troops to go over the top one more time. The Board members would turn out in force if a VIP was visiting the hospital for any reason. Otherwise, they were pretty much invisible.

Clinical Director (CD)

There are many different clinical departments in a hospital: adult medicine, medicine for older people (previously geriatrics), paediatrics, the ED, obstetrics and gynaecology, surgery (including upper GI, colorectal, orthopaedic and trauma, ENT, urology, maxillofacial, neurosurgery, cardiothoracic surgery, etc), anaesthesia, critical care. All the doctors within a department are managed by a Clinical Director, a senior consultant from that specialty appointed to the role by the CEO. The CD is effectively the CEO’s personal representative within a department and is responsible for departmental performance, protocols and policies, doctor appraisal, disciplinary matters, etc. At least, that’s the theory. In my experience, the CD of most departments was usually chosen by the consultants themselves, based on whose turn it was to be ‘It’. Not many senior clinicians were keen to take on the mantle of manager. Even fewer had the required skill set, and almost none had benefited from any formal management training.

Joint Local Negotiating Committee (JLNC)

The JLNC is the formal forum where the Executive Team meets up with representatives of the medical staff to discuss issues relating to hospital performance and to negotiate doctors’ terms and conditions of employment at a local level. It generally convenes about once every month or two. I know quite a bit about the workings of the JLNC because I was the Medical Staff Side Chair of our JLNC for six years – essentially the hospital doctors’ shop steward. The CEO was the Management Side JLNC Chair. You’ll have heard about people like me in the papers. Apparently I’m a left-wing, extremist, card-carrying member of the British Medical Association (the BMA is the doctors’ trade union), whose primary purpose in life is to bankrupt and destroy the NHS by maximising the already excessively generous pay of fat cat consultants and self-interested junior doctors, at the same time as minimising their workload, by the threat or actuality of industrial action.

In theory, JLNC meetings were chaired alternately by either me or our chief exec. However, most of the time the chief exec had better things to do/couldn’t be arsed/didn’t want to negotiate, and was deputised by the Medical Director, the Finance Director, or the Operational Development Director – whoever had been slowest off the mark to get in their apologies.

My six-year term as Chair was nothing if not educational. I learnt that hospital managers are not half as clever as they think they are. I learnt that negotiation is a tactic to give the impression that managers are listening to concerns and are generally sympathetic to them before imposing whatever it is they want to do, anyway. And I learnt that much of what exec teams strive to achieve over years of endeavour can be superseded at a stroke by the big cheeses above. There can be no better example than Matt Hancock’s magic-wand waving disappearing act of £13.4 b accumulated NHS debt during the COVID crisis.

Check out my website at https://www.drtonymccluskey.com for more details about my books and how you can read free chapters.

My three books, Vocation, Resuscitation, and Resignation, are available to purchase as ebooks or paperbacks at https://www.amazon.com/dp/B0DJ3273KH.

(https://www.amazon.co.uk/dp/B0DJ3273KH for readers in the UK).